Adjustment disorders

The emphasis in ICD-10(1!) is on emotional disturbance as the characteristic feature of adjustment disorders—some disturbance of behaviour is acknowledged, particularly in adolescence. However, it is common to encounter cognitive or behavioural changes that interfere with social functioning and quality of life, and yet which are not attributable to the consequences of mood disorder. DSM-IV(12) acknowledges this possibility more directly, including a category of 'Adjustment disorder, unspecified', which covers 'maladaptive reactions (e.g. physical complaints, social withdrawal, or work or academic inhibition)'.

Examples of cognitive problems are extreme helplessness, denial of the existence of illness, or of the handicap associated with it. Behavioural problems may include marked social withdrawal or lack of self-care, or irrational non-adherence to treatment. Emotional problems are typically thought of as anxiety or depression, but irritability is also common.

Diagnosis and differential diagnosis

The diagnostic features of adjustment disorders are relatively non-specific, comprising mood symptoms and behaviour disturbances which do not meet the criteria for a diagnosis of another disorder, and yet which are sufficient to amount to a mental disorder. The two main diagnostic questions are as follows.

• Does the patient have a diagnosable mental disorder?

• Is any change in mental state part of a normal response to illness?

If there is a mental disorder, should it be given another more specific label than 'adjustment disorder'?

What distinguishes normal adjustment from a disorder? The first criterion is whether the symptoms are persisting beyond the time when they might be attributable to the stressor. This judgement is relatively straightforward when the stressor is a single event. However, if illness is more persistent or intermittent—such as cancer followed by intensive treatment, or multiple sclerosis—then it is less easy to judge.

The second criterion is whether the response is causing avoidable social dysfunction. For example, in many cultures illness is followed by a period of convalescence, during which activity is reduced and a return to full social responsibilities is deferred. This may be a healthy avoidance of activity, if it allows full recovery from illness, but prolonged avoidance of activity may lead to secondary physical problems as well as social isolation and loss of role.

When adjustment disorders are associated with chronic illness and handicap, the duration criterion cannot apply. An individual may present because his or her response is outside the culturally acceptable range; for example, he or she may be too demanding or uncooperative, or too passive and dependent. It is unwise to regard a presentation as disordered simply on these grounds. The best indicator is whether the individual is achieving the highest level of function and the lowest level of distress of which they are capable under the circumstances. This means that each person must be diagnosed according to his or her own context, and that a standardized set of criteria cannot be applied.

The differentiation of adjustment disorders from other psychiatric disorders is more straightforward, and depends on the presence or absence of key symptoms. The main conditions found in association with physical illness are depressive disorders, anxiety disorders, and occasionally post-traumatic stress disorder.

Epidemiology

Little is known about the epidemiology of adjustment disorders other than those involving mood disturbance, because of the absence of standardized diagnostic criteria.

Psychiatric symptoms are distributed in the general population, with a positive skew to the distribution. In the physically ill, the same pattern of distribution is seen, but the curve is shifted to the right. The increase in psychiatric symptoms is contributed to by a general increase in all the common symptoms. The usual way to identify cases is to select those who cross an accepted threshold for symptom levels—as determined, for example, by one of the standardized self-report questionnaires—and then to apply diagnostic criteria. Adopting this approach, rates of diagnosable mood disorder among the physically ill are about double what they are in the general population. That is, 30 to 50 per cent (depending on the population studied and the diagnostic criteria employed) of the physically ill have a mental disorder. Approximately two-thirds of these cases are adjustment disorders, the rest meeting criteria for another disorder.

The elderly report lower rates of psychiatric disturbance. This may be a cultural effect, with the elderly disposed to report fewer symptoms of distress as a result of stoicism learned through experience of adversity earlier in life. Alternatively, the elderly may genuinely respond differently to physical illness.

Mood symptoms and adjustment disorders are more common in response to acute illness than they are in chronic illness.

Aetiology

There are several reasons why coping might fail.

First, demands may be overwhelming. The news that one has a terminal illness takes time to assimilate—to understand all its meanings, grasp all the threats and losses involved. While that process of appraisal is going on, it is difficult to marshal resources and use them effectively. This explains, in part, why mood disorder is more commonly associated with acute than chronic illness.

Second, resources may be inadequate or missing. One problem associated with physical illness is that it may impair personal resources as a primary effect of the disease process. Most importantly, many illnesses have effects on the central nervous system by virtue of the direct involvement of the brain or through the neurological effects of systemic disturbance.

Third, coping responses may be ineffective. There are few rules about what makes effective coping. In general, a broad and flexible repertoire is desirable, with a strong element of active problem-focused techniques. However not all illnesses, nor all aspects of a particular illness, are likely to be amenable to problem-focused coping. Probably the most effective coping is matched to the situation. That is, the coping matches the demands, so that heavy reliance is not placed on problem-focused coping when little in the situation can change, nor excessive use made of emotion-focused coping when active involvement in illness management is needed.

A common problem of failure to match coping to the situation is found in patients with chronic illness, who are responding to their circumstances as if they none the less had an acute illness. In acute illness, problem-focused coping often involves seeking reversal or even cure of the illness process, while emotion-focused coping involves dealing with the anxiety of uncertainty, or grieving if the prognosis is clearly poor. On the other hand, in chronic illness, problem-focused coping involves symptom management and maximizing function, while emotion-focused coping requires a degree of acceptance. Using the wrong coping repertoire leads to frustration.

It is not easy to predict who will develop an adjustment disorder. The most robust finding is that a previous history of psychiatric problems increases the risk of psychiatric problems associated with physical illness.

Course and prognosis

By definition, adjustment disorders arise shortly after diagnosis. In practice, there is variation; some people respond immediately and develop symptoms within days, while others develop symptoms weeks or even months after diagnosis. The losses associated with illness may only become apparent when a person leaves hospital and faces functional impairment at home. Carers and others in the social network respond differently to acute and chronic illness, and it may take time for that to become clear. The greater the delay from the onset of illness to the emergence of symptoms, the harder it is to make a diagnosis of adjustment disorder. In clinical practice, it is reasonable to set an upper limit of a year.

Most adjustment disorders provoked by new-onset illness, resolve within weeks. Slower recovery takes place over the 12 or 18 months. If recovery has not occurred by then, the patient has usually developed another mental disorder, such as a depressive disorder. Accurate data are few, but probably no more than 10 per cent of patients develop a prolonged adjustment disorder.

The psychiatric symptoms of adjustment disorder impair quality of life, so much so that all standardized quality-of-life measures include mood symptoms in their profile. Psychiatric morbidity associated with physical illness is also a risk factor for deliberate self-harm and for completed suicide. Adjustment disorders are also likely to have an effect on the outcomes of treatment for physical disease. (13) Health service costs are greater for patients with physical illness and psychiatric comorbidity; lengths of stay are longer for hospital inpatients; the functional outcomes of rehabilitation may be poorer, and there is some evidence that there may also be an increased mortality.

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